Eur J Ophthalmol 2014; 24 ( 5 ): 808-810
DOI: 10.5301/ejo.5000474
Case Report
Accidental foveal photocoagulation secondary to alexandrite laser Roberto Anaya-Alaminos, José I. Muñoz-Ávila, María C. González-Gallardo, Eduardo R. Mora-Horna, José L. García-Serrano, María V. Ramírez-Garrido Department of Ophthalmology, San Cecilio University Hospital, Granada - Spain
Purpose: In recent years, we have seen an increase in the use of laser systems in the field of aesthetics (mainly depigmentation and hair removal). Alexandrite laser is the most widely used. Methods: Case report. Results: We describe a case of retinal injury (foveal photocoagulation) directly related to an alexandrite laser hair removal procedure. Conclusions: Hair removal by laser systems is a fast and efficient method. The use of lasers without adequate protective measures or by unqualified personnel increases the risk of ocular adverse effects. Keywords: Alexandrite laser, Foveal photocoagulation, Laser exposure, Retinal injury Accepted: March 24, 2014
INTRODUCTION Alexandrite laser is mainly used for aesthetic purposes: depigmentation or hair removal. Currently, its growing use by unqualified personnel is increasing the risk of adverse effects (1). Although eye damage is infrequent, several cases of injuries in the anterior segment of the eye have been published. There is only one report of retinal injury because of alexandrite laser. In this report, we describe a case of retinal injury directly related to an alexandrite laser hair removal procedure.
DISCUSSION
Case report A 26-year-old woman came to the emergency room with visual loss in her left eye, secondary to an alexandrite laser (755 nm) hair removal procedure the day before, without the use of safety goggles or eye shields. The patient reported that the technician accidentally fired a shot into the air while she was looking at the laser terminal and immediately noticed the central scotoma in the left eye. Laser settings were 10 J/cm2 of energy and 5 milliseconds 808
of duration. Clinical examination of the left eye showed a visual acuity of 20/200 and a visual field with an important central scotoma. Dilated fundus examination showed a large round yellow lesion on the fovea, similar to a laser argon impact of 500 µm (Fig. 1A). Optical coherence tomography (OCT) of the fovea showed an intraretinal increase of reflectivity and disruption of the photoreceptor layer (Fig. 1B). After 1 year of follow-up, lesions are stable: visual acuity of 20/100, central scotoma, and foveal scar (Fig. 2).
In recent years, we have seen an increase in the use of laser systems in the field of aesthetics (mainly depigmentation and hair removal) due to easy application and longterm effectiveness. Alexandrite laser is the most widely used. Its technology uses the mechanism of selective photothermolysis (2), which consists of concentrating the energy through the surface of the skin at a targeted point where treatment is desired and where the laser is
© 2014 Wichtig Publishing - ISSN 1120-6721
Anaya-Alaminos et al
A
A
B
B
Fig. 1 - (A) Large round yellow lesion on the fovea. (B) Optical coherence tomography: intraretinal increase of reflectivity and disruption of the photoreceptor layer.
Fig. 2 - (A) Fundus photography and (B) optical coherence tomography obtained 1 year postinjury: foveal scar.
converted to thermal energy in order to dissolve the skin cells or the unwanted hair follicles with minimal effect on surrounding tissue. Due to this mechanism, several authors have described alexandrite laser hair removal as a safe procedure. However, in clinical practice, the energy transmission that occasionally occurs into surrounding tissues can produce adverse effects (3) such as burns, scars, pigment changes, and erythema. Laser radiation can damage the eye by different mechanisms: photomechanical, photothermal, or photochemical. Sometimes, several of them are involved in a particular case. Alexandrite laser (755 nm) hurts the retina mainly due to a photothermal effect (4). Melanin is densely concentrated in the retinal pigment epithelium (RPE). This chromophore absorbs light throughout the visible (400–720 nm) and near-infrared (720–1,400 nm) spectrum. When too much energy is concentrated in the RPE, heat is produced faster than it can be dissi-
pated and an increase in temperature takes place. This heating involves coagulation of proteins, cell death, and scarring. Regarding the alexandrite laser eye iatrogenic, the literature reports several cases of pathology of the anterior eye segment as uveitis, pupillary distortion (5), iris atrophy (6), and cataracts after hair removal sessions on the periocular area (eyebrows). One author (7) describes an injury in the posterior segment of the eye. This is probably due to the fact that patients with anterior segment injuries kept their eyes closed while undergoing hair removal on the periocular area, while in our case, as in the case reported by Lin et al (7), the patient received the laser impact secondary to an accidental shot into the air, with the eye open, in the absence of goggles, and without tissue interposition that could absorb energy, producing retinal damage: foveal photocoagulation in our case and macular hole in the case reported by Lin et al (7).
© 2014 Wichtig Publishing - ISSN 1120-6721
809
Retinal injury caused by alexandrite laser
CONCLUSION
Conflict of Interest Statement: None of the authors has conflict of interest with this submission.
Hair removal by laser systems is fast and efficient. Their use without adequate protective measures or by unqualified personnel increases the risk of ocular adverse effects, like the foveal photocoagulation described in this report. Financial Support: No financial support was received for this submission.
Address for correspondence: Roberto Anaya-Alaminos, MD Avenida Dr. Olóriz 16 18012 Granada Spain [email protected]
REFERENCES
4.
1.
5.
Vano-Galvan S, Jaen P. Complications of nonphysician-supervised laser hair removal: case report and literature review. Can Fam Physician 2009;55: 50-2. 2. Wanner M. Laser hair removal. Dermatol Ther 2005;18: 209-16. 3. Hammes S, Karsai S, Metelmann HR, et al. Treatment errors resulting from use of lasers and IPL by medical laypersons: results of a nationwide survey. . J Dtsch Dermatol Ges 2013;11:149-56.
810
6.
7.
Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol 2000;44:459-78. Lin CC, Tseng PC, Chen CC, Woung LC, Liou SW. Iritis and pupillary distortion after periorbital cosmetic alexandrite laser. Graefes Arch Clin Exp Ophthalmol 2011;249:783-5. Elkin Z, Ranka MP, Kim ET, Kahanowicz R, Whitmore WG. Iritis and iris atrophy after eyebrow epilation with alexandrite laser. Clin Ophthalmol 2011;5:1733-35. Lin LT, Liang CM, Chiang SY, Yang HM, Chang CJ. Traumatic macular hole secondary to a Q-switch Alexandrite laser. Retina 2005;25:662-5.
© 2014 Wichtig Publishing - ISSN 1120-6721
DOI: 10.5301/ejo.5000474
Case Report
Accidental foveal photocoagulation secondary to alexandrite laser Roberto Anaya-Alaminos, José I. Muñoz-Ávila, María C. González-Gallardo, Eduardo R. Mora-Horna, José L. García-Serrano, María V. Ramírez-Garrido Department of Ophthalmology, San Cecilio University Hospital, Granada - Spain
Purpose: In recent years, we have seen an increase in the use of laser systems in the field of aesthetics (mainly depigmentation and hair removal). Alexandrite laser is the most widely used. Methods: Case report. Results: We describe a case of retinal injury (foveal photocoagulation) directly related to an alexandrite laser hair removal procedure. Conclusions: Hair removal by laser systems is a fast and efficient method. The use of lasers without adequate protective measures or by unqualified personnel increases the risk of ocular adverse effects. Keywords: Alexandrite laser, Foveal photocoagulation, Laser exposure, Retinal injury Accepted: March 24, 2014
INTRODUCTION Alexandrite laser is mainly used for aesthetic purposes: depigmentation or hair removal. Currently, its growing use by unqualified personnel is increasing the risk of adverse effects (1). Although eye damage is infrequent, several cases of injuries in the anterior segment of the eye have been published. There is only one report of retinal injury because of alexandrite laser. In this report, we describe a case of retinal injury directly related to an alexandrite laser hair removal procedure.
DISCUSSION
Case report A 26-year-old woman came to the emergency room with visual loss in her left eye, secondary to an alexandrite laser (755 nm) hair removal procedure the day before, without the use of safety goggles or eye shields. The patient reported that the technician accidentally fired a shot into the air while she was looking at the laser terminal and immediately noticed the central scotoma in the left eye. Laser settings were 10 J/cm2 of energy and 5 milliseconds 808
of duration. Clinical examination of the left eye showed a visual acuity of 20/200 and a visual field with an important central scotoma. Dilated fundus examination showed a large round yellow lesion on the fovea, similar to a laser argon impact of 500 µm (Fig. 1A). Optical coherence tomography (OCT) of the fovea showed an intraretinal increase of reflectivity and disruption of the photoreceptor layer (Fig. 1B). After 1 year of follow-up, lesions are stable: visual acuity of 20/100, central scotoma, and foveal scar (Fig. 2).
In recent years, we have seen an increase in the use of laser systems in the field of aesthetics (mainly depigmentation and hair removal) due to easy application and longterm effectiveness. Alexandrite laser is the most widely used. Its technology uses the mechanism of selective photothermolysis (2), which consists of concentrating the energy through the surface of the skin at a targeted point where treatment is desired and where the laser is
© 2014 Wichtig Publishing - ISSN 1120-6721
Anaya-Alaminos et al
A
A
B
B
Fig. 1 - (A) Large round yellow lesion on the fovea. (B) Optical coherence tomography: intraretinal increase of reflectivity and disruption of the photoreceptor layer.
Fig. 2 - (A) Fundus photography and (B) optical coherence tomography obtained 1 year postinjury: foveal scar.
converted to thermal energy in order to dissolve the skin cells or the unwanted hair follicles with minimal effect on surrounding tissue. Due to this mechanism, several authors have described alexandrite laser hair removal as a safe procedure. However, in clinical practice, the energy transmission that occasionally occurs into surrounding tissues can produce adverse effects (3) such as burns, scars, pigment changes, and erythema. Laser radiation can damage the eye by different mechanisms: photomechanical, photothermal, or photochemical. Sometimes, several of them are involved in a particular case. Alexandrite laser (755 nm) hurts the retina mainly due to a photothermal effect (4). Melanin is densely concentrated in the retinal pigment epithelium (RPE). This chromophore absorbs light throughout the visible (400–720 nm) and near-infrared (720–1,400 nm) spectrum. When too much energy is concentrated in the RPE, heat is produced faster than it can be dissi-
pated and an increase in temperature takes place. This heating involves coagulation of proteins, cell death, and scarring. Regarding the alexandrite laser eye iatrogenic, the literature reports several cases of pathology of the anterior eye segment as uveitis, pupillary distortion (5), iris atrophy (6), and cataracts after hair removal sessions on the periocular area (eyebrows). One author (7) describes an injury in the posterior segment of the eye. This is probably due to the fact that patients with anterior segment injuries kept their eyes closed while undergoing hair removal on the periocular area, while in our case, as in the case reported by Lin et al (7), the patient received the laser impact secondary to an accidental shot into the air, with the eye open, in the absence of goggles, and without tissue interposition that could absorb energy, producing retinal damage: foveal photocoagulation in our case and macular hole in the case reported by Lin et al (7).
© 2014 Wichtig Publishing - ISSN 1120-6721
809
Retinal injury caused by alexandrite laser
CONCLUSION
Conflict of Interest Statement: None of the authors has conflict of interest with this submission.
Hair removal by laser systems is fast and efficient. Their use without adequate protective measures or by unqualified personnel increases the risk of ocular adverse effects, like the foveal photocoagulation described in this report. Financial Support: No financial support was received for this submission.
Address for correspondence: Roberto Anaya-Alaminos, MD Avenida Dr. Olóriz 16 18012 Granada Spain [email protected]
REFERENCES
4.
1.
5.
Vano-Galvan S, Jaen P. Complications of nonphysician-supervised laser hair removal: case report and literature review. Can Fam Physician 2009;55: 50-2. 2. Wanner M. Laser hair removal. Dermatol Ther 2005;18: 209-16. 3. Hammes S, Karsai S, Metelmann HR, et al. Treatment errors resulting from use of lasers and IPL by medical laypersons: results of a nationwide survey. . J Dtsch Dermatol Ges 2013;11:149-56.
810
6.
7.
Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol 2000;44:459-78. Lin CC, Tseng PC, Chen CC, Woung LC, Liou SW. Iritis and pupillary distortion after periorbital cosmetic alexandrite laser. Graefes Arch Clin Exp Ophthalmol 2011;249:783-5. Elkin Z, Ranka MP, Kim ET, Kahanowicz R, Whitmore WG. Iritis and iris atrophy after eyebrow epilation with alexandrite laser. Clin Ophthalmol 2011;5:1733-35. Lin LT, Liang CM, Chiang SY, Yang HM, Chang CJ. Traumatic macular hole secondary to a Q-switch Alexandrite laser. Retina 2005;25:662-5.
© 2014 Wichtig Publishing - ISSN 1120-6721
